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Ruckdeschel, Paul t. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit N ^ First T Midd'e Last Sex c c e h Mu It Date of Death Age If Veteran of U.S. Armed Forces, IN 3- 7-4D /3 7 0 War or Dates N'o • PLa_ce of Death (�- Hospital, Instituti�o��s� ]IS ) �� (Ciy)Town or Village G Ie r)5 l l IS Street Address (� C / H 0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W. Circumstances Investigation ill Medical Certifier Name Title 44. SU za. 1 ne-- i n AA D Address a-rC-k-11 c G ve c,i'1b U i�. I\y th Certificate File District-fd"umber Register Number Cit Town or Village( )r S 1 i S 5001 f 3D.. '>❑Burial Date ery oriCremato 1-413 I Mc_ 13 V l ei..t.) rzervta p >' ❑Entombment Add s gi' Cremation C.. ueQ..i'�� by iV y _ 0 Date ...J Place Removed Removal and/or Held and/or Address = Hold ffil 0 Date Point of 0 Li Transportation Shipment O by Common Destination Carrier 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address N Elis Permit Issued to nA Registration Number Name of Funeral Home I vi i j Ier fuV) 'i _I +11-)/'yam ©// I Address U 35 ) Stet 3 ind 1 a k) i--Ct k- i zeL Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address tr L CL Permission is hereby granted to dispose of the human remains desc ibed abo as i ed. Date Issued 4,) 1'i13 Registrar of Vital Statistics (signature) iiiil District Number 51c© / Place et - /- 0 f G s Tit //S I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LIU Date of Disposition q- -13 Place of Disposition -1",„.aOir_' Curr»;ff` . (address) la 1.0 1X (section) t' (lot number) (grave number) cName of Sexton or Person An Charge of Pre ises f..) HAW ► I (please print) Signature L L. Title c a ibrci . (over) DOH-1555 (02/2004)